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WORKERS' COMPENSATION SELECTION OF DESIGNATED MEDICAL <br />PROVIDER DISCLOSURE STATEMENT <br />If you select two Designated Medical Providers meeting the following qualifications, a premium credit will be <br />applied to your policy. For policies eligible for this credit as well as schedule rating, the combination of the 2.5% <br />credit and the schedule modification cannot exceed +/-25%. <br />A qualified Designated Medical Provider is a medical provider, who: <br />1) Has a knowledge of work injuries; <br />2) Is knowledgeable of fee schedules; <br />3) Is decisive on medical -maximum -improvement determinations; <br />4) Communicates with you, the employer on such issues as case management and wellness <br />programs; <br />5) Is knowledgeable of the employers operations. <br />The names of the providers must be posted and well publicized by you, the employer. <br />** SIGN AND RETURN ** <br />I am aware of the availability of a premium credit of 2.5%, if I select two qualified Designated Medical Providers. <br />For policies eligible for this credit as well as schedule rating, the combination of the 2.5% credit and the schedule <br />modification cannot exceed +/-25%. <br />Insured Signature <br />Policy Number 59 WEC AC9055 <br />Issuing Office THE HARTFORD BUSINESS SERVICE CENTER <br />Issuing Office 3600 WISEMAN BLVD <br />Address SAN ANTONIO TX 78251 <br />Form WC 66 02 81 C Printed in U.S.A. <br />Process Date: 05/25/20 <br />J�N <br />RAMmWmentDMsian <br />REVIEWED&APPROVEDSY:Policy ;Vl <br />--� Risk Pjanagement Analyst <br />